Healthcare Provider Details

I. General information

NPI: 1477174985
Provider Name (Legal Business Name): HANNAN ASGHAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date: 01/11/2022
Reactivation Date: 06/08/2022

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073
US

IV. Provider business mailing address

2001 KINGSLEY AVE - GRADUATE MEDICAL EDUCATION
ORANGE PARK FL
32073
US

V. Phone/Fax

Practice location:
  • Phone: 904-639-2005
  • Fax: 904-639-2015
Mailing address:
  • Phone: 904-639-2005
  • Fax: 904-639-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTRN31747
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: